Provider Demographics
NPI:1114212461
Name:DR TIMOTHY BERGER
Entity Type:Organization
Organization Name:DR TIMOTHY BERGER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:260-482-4202
Mailing Address - Street 1:1620 SAINT JOE RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1434
Mailing Address - Country:US
Mailing Address - Phone:260-482-4202
Mailing Address - Fax:260-482-5232
Practice Address - Street 1:1620 SAINT JOE RIVER DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1434
Practice Address - Country:US
Practice Address - Phone:260-482-4202
Practice Address - Fax:260-482-5232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty